

<title>FORM PEMESANAN</title>


<style type="text/css">

body {
  background: #f1eee2;
  color: #008eb1;
  font-family: Vollkorn,Georgia,'Times New Roman',serif;
  padding-top: 0em;
}
div.ss-form-container {
  background: #008eb1;
  background: rgba(0,142,177,.75);
  border: 2px solid #fbfaf7;
  border-radius: 5px;
  font-size: 1.2em;
  line-height: 1.6em;
  margin: 0 auto;
  max-width: 800px;
  padding: 1em;
  width: 80%;
}
input, select, textarea {
  font-family: Tahoma,Arial,serif;
  font-size: 13px;
}
div.ss-form-heading, div.ss-form, div.ss-footer, div.ss-submit-message {
  background: #fbfaf7;
  border: 2px solid #008eb1;
  margin: 0 0 1em;
  padding: 1em;
  border-radius: 5px;
}
h1.ss-form-title {
  font-family: 'Lobster';
  font-size: 2.4em;
  line-height: 1.3em;
  text-align: center;
}
div.errorheader {
  margin: 1em 0;
  padding: 1em;
  border-radius: 5px;
}
div.errorbox-bad {
  background: none;
  border: none;
  color: #b10007;
  padding: 0;
}
div.errorbox-bad div.ss-form-entry, div.errorheader {
  background: #fdd;
  border: 2px solid #b10007;
}
h2.ss-section-title, h2.ss-page-title {
  background: none;
  font-family: 'Lobster';
  font-size: 2em;
  line-height: 1.3em;
  margin: 0;
  padding: 0;
}
.errorbox-good label, .errorbox-bad label, .ss-terms a {
  color: #008eb1;
}
.ss-required-asterisk {
  color: #b10007;
}
td.ss-scalenumbers, td.ss-scalerow, td.ss-gridnumbers, td.ss-gridrow, tr.ss-grid-row-odd, tr.ss-grid-row-even {
  border-color: #008eb1;
}
tr.ss-grid-row-odd {
  background: #fbfaf7;
}
tr.ss-grid-row-even {
  background: #f1eee2;
}
label.ss-q-help {
  color: #999;
}
td.ss-scalenumbers, td.ss-scalerow, td.ss-leftlabel, td.ss-rightlabel, label.ss-gridnumber, span.ss-powered-by, .ss-powered-by a:link, .ss-powered-by a:visited, span.ss-terms {
  color: #008eb1;
}

</style>

<script type="text/javascript">
        /**
 * @license
 *! H5F
 * https://github.com/ryanseddon/H5F/
 * Copyright (c) Ryan Seddon | Licensed MIT
 */

(function(e,t){"function"==typeof define&&define.amd?define(t):e.H5F=t()})(this,function(){var e,t,a,i,n,r,s,l,u,o,c,d,v,f,p,m,h,g,b,y,w,C,N,A,E,$,k=document,x=k.createElement("input"),q=/^[a-zA-Z0-9.!#$%&'*+-\/=?\^_`{|}~-]+@[a-zA-Z0-9-]+(?:\.[a-zA-Z0-9-]+)*$/,M=/[a-z][\-\.+a-z]*:\/\//i,L=/^(input|select|textarea)$/i;return r=function(e,t){var a=!e.nodeType||!1,i={validClass:"valid",invalidClass:"error",requiredClass:"required",placeholderClass:"placeholder"};if("object"==typeof t)for(var r in i)t[r]===void 0&&(t[r]=i[r]);if(n=t||i,a)for(var l=0,u=e.length;u>l;l++)s(e[l]);else s(e)},s=function(a){var i,n=a.elements,r=n.length,s=!!a.attributes.novalidate;if(b(a,"invalid",u,!0),b(a,"blur",u,!0),b(a,"input",u,!0),b(a,"keyup",u,!0),b(a,"focus",u,!0),b(a,"change",u,!0),b(a,"click",o,!0),b(a,"submit",function(i){e=!0,t||s||a.checkValidity()||w(i)},!1),!v())for(a.checkValidity=function(){return c(a)};r--;)i=!!n[r].attributes.required,"fieldset"!==n[r].nodeName.toLowerCase()&&l(n[r])},l=function(e){var t=e,a=g(t),n={type:t.getAttribute("type"),pattern:t.getAttribute("pattern"),placeholder:t.getAttribute("placeholder")},r=/^(email|url)$/i,s=/^(input|keyup)$/i,l=r.test(n.type)?n.type:n.pattern?n.pattern:!1,u=f(t,l),o=m(t,"step"),v=m(t,"min"),h=m(t,"max"),b=!(""===t.validationMessage||void 0===t.validationMessage);t.checkValidity=function(){return c.call(this,t)},t.setCustomValidity=function(e){d.call(t,e)},t.validity={valueMissing:a,patternMismatch:u,rangeUnderflow:v,rangeOverflow:h,stepMismatch:o,customError:b,valid:!(a||u||o||v||h||b)},n.placeholder&&!s.test(i)&&p(t)},u=function(e){var t=C(e)||e,a=/^(input|keyup|focusin|focus|change)$/i,r=/^(submit|image|button|reset)$/i,s=/^(checkbox|radio)$/i,o=!0;!L.test(t.nodeName)||r.test(t.type)||r.test(t.nodeName)||(i=e.type,v()||l(t),t.validity.valid&&(""!==t.value||s.test(t.type))||t.value!==t.getAttribute("placeholder")&&t.validity.valid?(A(t,[n.invalidClass,n.requiredClass]),N(t,n.validClass)):a.test(i)?t.validity.valueMissing&&A(t,[n.requiredClass,n.invalidClass,n.validClass]):t.validity.valueMissing?(A(t,[n.invalidClass,n.validClass]),N(t,n.requiredClass)):t.validity.valid||(A(t,[n.validClass,n.requiredClass]),N(t,n.invalidClass)),"input"===i&&o&&(y(t.form,"keyup",u,!0),o=!1))},c=function(t){var a,i,n,r,s=!1;if("form"===t.nodeName.toLowerCase()){a=t.elements;for(var l=0,o=a.length;o>l;l++)i=a[l],n=!!i.attributes.required,r=!!i.attributes.pattern,"fieldset"!==i.nodeName.toLowerCase()&&(n||r&&n)&&(u(i),i.validity.valid||s||(e&&i.focus(),s=!0));return!s}return u(t),t.validity.valid},d=function(e){var t=this;t.validationMessage=e},o=function(e){var a=C(e);a.attributes.formnovalidate&&"submit"===a.type&&(t=!0)},v=function(){return E(x,"validity")&&E(x,"checkValidity")},f=function(e,t){if("email"===t)return!q.test(e.value);if("url"===t)return!M.test(e.value);if(t){var i=e.getAttribute("placeholder"),n=e.value;return a=RegExp("^(?:"+t+")$"),n===i?!1:""===n?!1:!a.test(e.value)}return!1},p=function(e){var t={placeholder:e.getAttribute("placeholder")},a=/^(focus|focusin|submit)$/i,r=/^(input|textarea)$/i,s=/^password$/i,l=!!("placeholder"in x);l||!r.test(e.nodeName)||s.test(e.type)||(""!==e.value||a.test(i)?e.value===t.placeholder&&a.test(i)&&(e.value="",A(e,n.placeholderClass)):(e.value=t.placeholder,b(e.form,"submit",function(){i="submit",p(e)},!0),N(e,n.placeholderClass)))},m=function(e,t){var a=parseInt(e.getAttribute("min"),10)||0,i=parseInt(e.getAttribute("max"),10)||!1,n=parseInt(e.getAttribute("step"),10)||1,r=parseInt(e.value,10),s=(r-a)%n;return g(e)||isNaN(r)?"number"===e.getAttribute("type")?!0:!1:"step"===t?e.getAttribute("step")?0!==s:!1:"min"===t?e.getAttribute("min")?a>r:!1:"max"===t?e.getAttribute("max")?r>i:!1:void 0},h=function(e){var t=!!e.attributes.required;return t?g(e):!1},g=function(e){var t=e.getAttribute("placeholder"),a=/^(checkbox|radio)$/i,i=!!e.attributes.required;return!(!i||""!==e.value&&e.value!==t&&(!a.test(e.type)||$(e)))},b=function(e,t,a,i){E(window,"addEventListener")?e.addEventListener(t,a,i):E(window,"attachEvent")&&window.event!==void 0&&("blur"===t?t="focusout":"focus"===t&&(t="focusin"),e.attachEvent("on"+t,a))},y=function(e,t,a,i){E(window,"removeEventListener")?e.removeEventListener(t,a,i):E(window,"detachEvent")&&window.event!==void 0&&e.detachEvent("on"+t,a)},w=function(e){e=e||window.event,e.stopPropagation&&e.preventDefault?(e.stopPropagation(),e.preventDefault()):(e.cancelBubble=!0,e.returnValue=!1)},C=function(e){return e=e||window.event,e.target||e.srcElement},N=function(e,t){var a;e.className?(a=RegExp("(^|\\s)"+t+"(\\s|$)"),a.test(e.className)||(e.className+=" "+t)):e.className=t},A=function(e,t){var a,i,n="object"==typeof t?t.length:1,r=n;if(e.className)if(e.className===t)e.className="";else for(;n--;)a=RegExp("(^|\\s)"+(r>1?t[n]:t)+"(\\s|$)"),i=e.className.match(a),i&&3===i.length&&(e.className=e.className.replace(a,i[1]&&i[2]?" ":""))},E=function(e,t){var a=typeof e[t],i=RegExp("^function|object$","i");return!!(i.test(a)&&e[t]||"unknown"===a)},$=function(e){for(var t=document.getElementsByName(e.name),a=0;t.length>a;a++)if(t[a].checked)return!0;return!1},{setup:r}});

      </script>

<link href="https://docs.google.com/forms/oembed?url=https://docs.google.com/forms/d/1ybFzL2ex_e8aNtubnPSk5xhq_uIP430V6G3xDfANitA/viewform&amp;format=xml" rel="alternate" type="text/xml+oembed"></link>


<link href="/static/forms/client/css/1967885759-mobile_formview_ltr.css" media="screen and (max-device-width: 721px)" rel="stylesheet" type="text/css"></link>

<style type="text/css">
<!--
.style1 {
 font-family: "Times New Roman", Times, serif;
 font-style: italic;
}
.style2 {font-family: "Times New Roman", Times, serif}
-->
</style>

</head>
<body class="ss-base-body" dir="ltr"><div itemscope="" itemtype="http://schema.org/CreativeWork/FormObject">

<div class="ss-form-container">
<div class="ss-top-of-page">
<div class="ss-form-heading">
<h1 class="ss-form-title" dir="ltr">
FORM PEMESANAN</h1>
<div class="ss-form-desc ss-no-ignore-whitespace">
Lengkapi Form di bawah ini untuk memudahkan kami</div>
<hr class="ss-email-break" style="display: none;" />
<div class="ss-required-asterisk">
* <span class="style1">Wajib Diisi</span> </div>
</div>
</div>
<div class="ss-form">


<script type="text/javascript">var submitted=false;</script>
    <iframe id="hidden_iframe" name="hidden_iframe" onload="if(submitted) 

{window.location='http://laribashop.blogspot.com';}" style="display: none;"></iframe>
      <form action="https://docs.google.com/forms/d/1ybFzL2ex_e8aNtubnPSk5xhq_uIP430V6G3xDfANitA/formResponse" method="POST" onsubmit="submitted=true;" target="hidden_iframe">

<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_142773613"><div class="ss-q-title">
Kode Barang
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label>
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="Kode Barang  " aria-required="true" class="ss-q-short" dir="auto" id="entry_142773613" name="entry.142773613" required="" title="" type="text" value="" />
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_1149504055"><div class="ss-q-title">
Nama
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label> 
Pemesan
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="Nama  " aria-required="true" class="ss-q-short" dir="auto" id="entry_1149504055" name="entry.1149504055" required="" title="" type="text" value="" />
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-paragraph-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_1942672355"><div class="ss-q-title">
Nama Jalan
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label><span class="ss-q-help ss-secondary-text style1">sertakan RT/RW jika ada</span><span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<textarea aria-label="Nama Jalan sertakan RT/RW jika ada " aria-required="true" class="ss-q-long" cols="20: auto" id="entry_1942672355" name="entry.1942672355" required="" rows=""></textarea>
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_1723141060"><div class="ss-q-title">
Kodya/Kab.
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label>
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="Kodya/Kab.  " aria-required="true" class="ss-q-short" dir="auto" id="entry_1723141060" name="entry.1723141060" required="" title="" type="text" value="" />
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_828635043"><div class="ss-q-title">
Propinsi
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label>
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="Propinsi  " aria-required="true" class="ss-q-short" dir="auto" id="entry_828635043" name="entry.828635043" required="" title="" type="text" value="" />
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_1811801942"><div class="ss-q-title">
Kode Pos
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label>
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="Kode Pos  " aria-required="true" class="ss-q-short" dir="auto" id="entry_1811801942" name="entry.1811801942" required="" title="" type="text" value="" />
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_1895808569"><div class="ss-q-title">
No. Telp/HP
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label>
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="No. Telp/HP  " aria-required="true" class="ss-q-short" dir="auto" id="entry_1895808569" name="entry.1895808569" required="" title="" type="text" value="" />
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item  ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_1528777364"><div class="ss-q-title">
Alamat Email
</div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="Alamat Email  Must be a valid email address" class="ss-q-short" dir="auto" id="entry_1528777364" name="entry.1528777364" title="Must be a valid email address" type="email" value="" />
<span class="error-message style2"><em>Pastikan alamat email valid </em></span>
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item  ss-paragraph-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_2056398805"><div class="ss-q-title">
Berita
</div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<textarea aria-label="Berita  " class="ss-q-long" cols="20: auto" id="entry_2056398805" name="entry.2056398805" rows=""></textarea>
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-radio" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_1681003357"><div class="ss-q-title">
Pembayaran via
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label>
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<label><span class="ss-choice-item-control goog-inline-block">
<input aria-label="Bank Mandiri" class="ss-q-radio" id="group_1080422327_1" name="entry.1080422327" required="" role="radio" type="radio" value="Bank Mandiri" />
</span>
<span class="ss-choice-label">Bank Mandiri</span>
</label>
<label><span class="ss-choice-item-control goog-inline-block"><input aria-label="Bank BCA" class="ss-q-radio" id="group_1080422327_2" name="entry.1080422327" required="" role="radio" type="radio" value="Bank BCA" /></span>

<span class="ss-choice-label">Bank BCA</span></label>
<label><span class="ss-choice-item-control goog-inline-block">
<input class="ss-q-radio ss-q-other-toggle" id="group_1080422327_3" name="entry.1080422327" role="radio" type="radio" value="__other_option__" />
</span>
Other:</label>
<span class="ss-q-other-container goog-inline-block">
<input aria-label="Other" class="ss-q-other" dir="auto" id="entry_1080422327_other_option_response" name="entry.1080422327.other_option_response" type="text" value="" />
</span>
<div class="error-message">
</div>
<div class="required-message">
</div>
</div>
</div>
</div>
<div class="ss-form-question errorbox-good">
<div class="ss-item ss-item-required ss-text" dir="ltr">
<div class="ss-form-entry">
<label aria-hidden="true" class="ss-q-item-label" for="entry_565649308"><div class="ss-q-title">
Dari Nomor Rekening
<label aria-label="(Required field)" for="itemView.getDomIdToLabel()"></label>
<span class="ss-required-asterisk">*</span></div>
<div class="ss-q-help ss-secondary-text" dir="ltr">
</div>
</label>
<input aria-label="Dari Nomor Rekening  " aria-required="true" class="ss-q-short" dir="auto" id="entry_565649308" name="entry.565649308" required="" title="" type="text" value="" />
<div class="error-message">
</div>
<div class="required-message">
</div>
<input name="draftResponse" type="hidden" value="[,,&quot;4030833521605707833&quot;]
" />
  <input name="pageHistory" type="hidden" value="0" />
  <input name="fromEmail" type="hidden" value="false" />
  
  <input name="fbzx" type="hidden" value="4030833521605707833" />
<br />

<br />

<div class="ss-item ss-navigate">
<table id="navigation-table"><tbody>
<tr><td class="ss-form-entry goog-inline-block" dir="ltr" id="navigation-buttons">
<input id="ss-submit" name="submit" type="submit" value="Submit" />
<div class="ss-secondary-text">
<strong><em>Dilarang melakukan "submit" jika tidak memesan.</em></strong></div>
</td>
<td id="progress-container">&nbsp;</td></tr>
</tbody></table>
</div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
</body></html>

<br />
<div aria-atomic="" aria-live="assertive" class="docs-a11y-ariascreenreader-speakable docs-offscreen" id="docs-aria-speakable" role="region">
</div>
